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Pathogenesis and symptomatology of cholelithiasis in childhood. A prospective study
P Schweizer1, M P Lenz, H J Kirschner
1Department of Pediatric Surgery, University of Tübingen, Germany.
Insights
Gallstones in children can develop without gallbladder issues, with varying stone composition across age groups. Risk factors include TPN, obesity, and hormonal contraception, necessitating long-term ultrasound monitoring.
Area of Science:
- Pediatric Gastroenterology
- Hepatobiliary Surgery
- Pediatric Surgery
Background:
- Gallstones in children typically lack association with hemolytic disorders or gallbladder malformations.
- Existing literature on pediatric gallstone etiology is limited due to small case numbers.
- A 30-year prospective study addresses the development of gallstones in children without apparent underlying causes.
Purpose of the Study:
- To investigate the development of gallstones in children without hemolytic disorders or gallbladder abnormalities.
- To analyze changes in gallstone incidence across different pediatric age groups over 30 years.
- To identify risk factors and etiological differences in pediatric gallstone formation.
Main Methods:
- Prospective analysis of 111 children with symptomatic gallstones (no hemolytic disease).
- 30-year follow-up including clinical, radiological (ultrasound), and biochemical evaluations.
- Histological analysis of gallbladder specimens and spectroscopic analysis of stones and bile.
Main Results:
- Gallstone composition and lithogenesis causes varied significantly across four pediatric age groups.
- Identified risk factors: long-term total parenteral nutrition (TPN), post-cardiopulmonary bypass, extensive small bowel resection, obesity, and hormonal contraception in girls.
- Gallbladder morphology was normal in 61% of cases; increased gallstone incidence observed only in infants under 1 year.
Conclusions:
- Gallstones in children can arise from diverse factors beyond hemolytic conditions or gallbladder malformations.
- Specific pediatric populations (e.g., those with TPN, obesity) require vigilant, long-term ultrasound surveillance for gallstone detection.
- The study highlights evolving trends in pediatric gallstone disease, particularly an increase in infants.
Questions:
How may gallstones develop if there is no hemolytic disorder and no malformation or alteration of the gallbladder and cystic ducts? Was there a change in the incidence of stones and the assignment of the patients to different age groups? The literature gives answers to these questions on the basis of only few cases. Therefore, a relatively large prospective database of collected cases during 30 years shall be used to give additional answers.
Methods:
The data are derived from 111 children with symptomatic gallstones without hemolytic diseases. 109 of them required operative therapy. They were examined preoperatively and postoperatively maximum during 30 years of follow-up as well according to a defined program. This program includes taking the patient's history, evaluation of clinical, radiological including sonographical examination, exclusion of hemolytic primary diseases, histological investigation of intraoperatively gained specimens of the gallbladder, and the spectroscopic qualitative as well as semiquantitative analysis of stones and bile.
Results:
(1) The qualitative and quantitative composition of the stones is different in the four age groups. (2) The causes of lithogenesis are different in the four age groups. (3) Children with long-term TPN, after cardiopulmonary bypass operations, after extended small bowel resection, suffering from obesity, and girls using hormonal contraception are at risk of developing gallstones. We recommend to observe these patients by repeated ultrasound controls for gallstone formation during a minimum of 10 years. (4) Malformations and pathological alterations of the gallbladder are rare causes for increased lithogenity. The gallbladder appeared morphologically normal in 61% of patients with symptomatic gallstones. (5) An increased frequency of gallstones during the last 30 years was only observed in the age group under 1 year.